Bias, Anyone?

The following is a statement developed by Dr. Gerard W. Clum, Executive Director, of The Rubicon Group, in response to the Funk, et al. article, “The prevalence of the term subluxation in chiropractic degree program curricula throughout the world”. The article was published in Chiropractic & Manual Therapies in 2018. (Chiropr Man Therap. 2018; 26: 24),with thanks to Dr. Heidi Haavik for her review and suggestions.

Authors from the University of Bridgeport, College of Chiropractic and Bethune Cookman University recently published an article entitled: “The prevalence of the term subluxation in chiropractic degree program curricula throughout the world”. The article was published in Chiropractic & Manual Therapies in 2018. (Chiropr Man Therap. 2018; 26: 24)

According to the article’s abstract: “This research sought to determine how many chiropractic institutions worldwide still use the term in their curricula and to expand upon the previous work of Mirtz & Perle.” The goals of the article were further elucidated upon in the body of the article as being to: “…to expand upon the previous work of Mirtz and Perle to determine the prevalence of the term subluxation in the course tittles or descriptions in all chiropractic training programs around the world for which we could find information.”

In their effort to “determine how many chiropractic institutions worldwide still use the term in their curricula” and “to determine the prevalence of the term subluxation in the course tittles or descriptions in all chiropractic training programs around the world” the authors were true to their stated objectives. Had they kept their commentary to the quantitative elements they sought to measure and report on, there would be little else to say in commenting on the effort.

Unfortunately, the authors chose to contaminate their factual data collection by interjecting their biases on the use of the term “subluxation” within the chiropractic community. It appears that the de facto purpose of the article was not to present data to understand how frequently the term “subluxation” is used in academic catalogues or institutional websites. Rather the purpose of the article was to advance a negative view on the term subluxation using the frequency data as justification for the negativity.

These authors have taken a subject holding clinical and scientific importance in the profession and reducing it to a discussion of opinion. In addition, these authors have bootstrapped comments from various articles to support their biases while overlooking commentary from the same articles that undermines their views. Their diatribe against the use of the term “subluxation” in chiropractic is based largely on a 2005 article by Keating et al. (Chiropr Osteopat. 2005;13:17) that was critical of the dogmaticuse of the term “subluxation” as opposed to the use of the term “subluxation” itself. In fact, Keating noted:

“There is nothing inherently dogmatic or anti-scientific in the notion that an articular lesion may have health consequences, or that correction of joint dysfunction may relieve symptoms and/or improve health. Neither does our current inability to predict the effects (if any) of subluxation and/or the benefits of subluxation-correction relegate this hypothetical construct to the dustbin of clinical theories.”

As to the value of their own efforts, Keating and associates comment in their article summary:

“This brief review of the role of subluxation dogma in clinical practice, in marketing, in the legal and political arenas, as a basis for professional identity, and in the rhetoric of leading chiropractic organizations and agencies, is not a statement about subluxation’s validity or lack thereof.” [Emphasis added]

Following a careful review of the paper a distinction was made between statements of fact related to the intent of the study and statements of opinion offered in response to the quantitative data derived by the study. The first example of this non-sequitur commentary can be found in the article’s conclusion:

Conclusions

The term subluxation was found in all but two US course catalogues. The use of subluxation in US courses rose from a mean of 5.53 in 2011 to 6.50 in 2017. US institutions use the term significantly more frequently than non-US. Possible reasons for this were discussed. Unscientific terms and concepts should have no place in modern education, except perhaps in historical context. Unless these outdated concepts are rejected, the chiropractic profession and individual chiropractors will likely continue to face difficulties integrating with established health care systems and attaining cultural authority as experts in conservative neuro-musculoskeletal health care.”

The conclusion statement can readily be divided into two distinct sets of comments, the first reflecting the goals and outcome of the study and the second seeking to use that data to advance an anti-subluxation agenda under the guise of research:

“The term subluxation was found in all but two US course catalogues. The use of subluxation in US courses rose from a mean of 5.53 in 2011 to 6.50 in 2017. US institutions use the term significantly more frequently than non-US. Possible reasons for this were discussed.”

“Unscientific terms and concepts should have no place in modern education, except perhaps in historical context. Unless these outdated concepts are rejected, the chiropractic profession and individual chiropractors will likely continue to face difficulties integrating with established health care systems and attaining cultural authority as experts in conservative neuro-musculoskeletal health care.”

The animus driving the authors of this article is revealed in the extent to which they argue in the extreme and then apply that argument across the entire spectrum. For example, the authors go back to the 19thcentury for their basis of argument against the use of the term subluxation in the 21stcentury, citing the writings of D.D. Palmer. They then make a remarkable logical error discussing the writings of Palmer. The authors noted:

“Daniel David Palmer, the founder of chiropractic, stated that the science, art and philosophy of chiropractic comprise the three essential areas of knowledge for the profession.”

They then go on to comment:

“Included in this philosophy is the subluxation, …”

As Palmer noted there are three essential areas of knowledge for the chiropractor, comprising a science element, an art element and a philosophical (or conceptual) element of the discipline. These are three related, yet distinct aspect of the profession’s knowledge. Funk et al. fail to appreciate this distinction and they default to an argument that allaspects of chiropractic are philosophic in nature.

This illogical extension of their bias is reflected further in their commentary:

“The philosophical underpinnings of chiropractic have centered around the nervous system and, in more recent times, the effect of the vertebral subluxation complex on the nervous system’s functional role in other organ systems.”

The scientific thought supporting the profession is consistent with understanding the role of the relationship between structure and function, especially as it relates to the spine and the nervous system. Calling the nervous system’s intimate involvement with the spine, and its role in overall health and function a philosophical underpinning is absurd and ignores volumes/decades of scientific evidence.

The authors continue their extremism asserting a question of patient safety in a model of practice that has never been advocated in the history of the profession by commenting:

“This raises an important question: will patients in an exclusively subluxation based model receive optimal diagnoses and treatments? Croft et al. [47] stated that clinical practice should focus on “improving outcomes for patients in their total biological, psychological, and social environment and away from an exclusive and narrow focus on underlying disease as the determinant of outcome.” A practice that is exclusively subluxation based, thus driven by the doctor’s belief in the subluxation, cannot be evidence based. Such a practitioner will disregard important comorbidities that have been identified through empirical evidence that go beyond the subluxation and yet are amenable to care provided by a patient centered, evidence based practice chiropractors.”

Funk et al. base a significant portion of their argument on the idea that there exists an “exclusively subluxation based” model, i.e. one that will disregard all aspects of patient presentation beyond a subluxation. Such simply does not exist. The assertion and promotion of such an argument is irresponsible and evidences the lack of reality and objectivity these authors have brought to this discussion. Further, it is an argument that seeks only to inflame and deepen divisions within the profession.

It is unquestioned that chiropractors have used the term “subluxation” in a dogmatic manner. It is unquestioned that further research to understand the implications of joint dysfunction and the characteristics that are associated with it is needed. Neither of these however support the abandonment of the term “subluxation” by chiropractors in research, publication, education, or clinical practice. To the contrary the exciting neuroscience developments of the past 20 years, calls for a far more finite understanding of the nuances of joint dysfunction, especially spinal joints, and the association with abnormal function and state of ill-health.